Medical Records Coder and Summariser

3 months ago

Calne, United Kingdom Northlands Surgery Full time

Job summary

We are a busy and growing doctors surgery in Calne, Wiltshire, looking for a new team member to work as a Medical Records Coder and Summariser.

Full and part-time hours considered.

The main responsibility is to administrate clinical correspondence ( hospital clinic letters) such that the GP's only see items they need to action and the rest is on the patients record ready for their next interaction. This involves following a strict protocol which ensures safety,

To thrive in this role, you will enjoy lots of data entry, summarising and analysis to understand the implications of what you are coding, filing or forwarding to GP's.

Accuracy and attention to detail are of upmost importance.

You will need to develop a broad understanding of General Practice and an in-depth knowledge of medical terminology and coding, with on-the-job and external training.

Main duties of the job

CODING

Identify relevant clinical information contained in patient correspondence.

Code or free text the clinical information onto the patient record.

Deal with queries relating to coding.

SUMMARISING

Culling and sorting patient records and letters in preparation for summarising.

Reviewing medical records and producing an accurate summary of the patient's medical history.

Coding the information into the practice system.

Filing and retrieving paperwork.

SCANNING

Scan patient related documents onto their medical record using codes agreed by the clinical team.

Add any additional information about the source of the document.

Forward the document to the doctor or nurse who initiated the referral or who is most appropriate to receive the information.

About us

Team Northlands is a busy, friendly and supportive training practice in the heart of beautiful Wiltshire. For more information about us and our services, please go to

GMS practice with 13,700 patients Good CQC rating SystmOne / Ardens High QOF achievement Experienced clinical team Excellent admin support Actively involved in our ICB and PCN Thriving Patient Participation Group Independent pharmacy attached.

This job ad may close earlier than the closing date if sufficient applications are received.

Job description

Job responsibilities

To ensure all incoming and internal patient correspondance is stored on/in the patient's medical record and relevant information is coded.

To be able o locate documents as needed by the clinical and non-clinical staff.

To carry out administrative related tasks as delegated by the doctors and non-clinical staff.

The post holder will summarise and read code relevant information from the patient's clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health and Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, to include:

Using personal security systems within the workplace according to practice guidelines Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks Making effective use of training to update knowledge and skills Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards Reporting potential risks identified.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Professional / Personal Development

The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include:

Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality

The post-holder will strive to maintain quality within the practice, and will:

Alert other team members to issues of quality and risk Assess own performance and take accountability for own actions, either directly or under supervision Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance Work effectively with individuals in other agencies to meet patients needs Effectively manage own time, workload and resources.

Communication:

The post-holder should recognize the importance of effective communication within the team and will strive to:

Communicate effectively with other team members Communicate effectively with patients and carers Recognize peoples needs for alternative methods of communication and respond accordingly. Person Specification

Qualifications

Essential

Good level of education including GCSE grade A to C in English and Maths

Desirable

Evidence of Medical Terminology training. Evidence of Read Code training.

Experience

Essential

12 months+ experience in clinical coding and summarising. Knowledge of anatomical terms. Good IT skills - able to use Microsoft Office and learn how to use new applications.

Desirable

Experience of working in a healthcare setting. Previous knowledge of TPP SystmOne.

Personal Qualities and Skills

Essential

Detail orientated person. Reliable, trustworthy and conscientious. Self-starter, able to take direction and work as part of a team. Able to enter information accurately and consistently. Able to concentrate for prolonged periods of time. Good analytical skills. Good problem solving skills. Ability to manage time and workload. Ability to deal with all matters in a confidential manner. Willingness to help cover for leave of other staff.

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